Access to Specialty Care for Children (You can’t fix what you don’t measure)

Karin Verlaine Rhodes, MD MSDirector, Center for Emergency Care Policy & Research

Department of Emergency MedicinePerelman School of Medicine

University of Pennsylvania

2015 AAP National Conference & Exhibition, Washington DC

No Conflicts: Many Acknowledgments

The state of Illinois provided funding and support Provision of detailed physician licensure data

Medicaid and state employee health insurance claims data

Dummy Medicaid identification numbers

Heath & Disability Advocates, the Sargent Shriver National Center on Poverty Law, Goldberg & Kohn, Fredrick Cohen J.D.

Members of our expert review panel:

Diana Becker-Cutts, MD, HCMC

Genevieve Kenny, PhD – The Urban Institute

Daniel Polsky PhD, LDI, UPenn

The University of Chicago Survey Lab

Joanna Bisgaier, MSW PhD, Project Director

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Measuring Access to Specialty Care Experimental design (Simulated patients)

Results (Pre-ACA): Disparities exist by insurance status Varied by practice characteristics

The ACA quality and cost goals Implications for Specialty Care?

Clinic

Overview3

Why Study Access to Care?

Quality carePatient centered care

Advanced careGood Outcomes

Professionalism

Access is a prerequisite to quality!

Children’s Access to Specialty Care

Simulated Patient Methodology

Trained research assistants (simulated mothers) called randomly selected subspecialty clinics -> earliest appointment

Computer-assisted telephone interview Scripts iteratively developed/ reviewed by experts

in each field and piloted Standardized responses to questions

Paired calls at least 4 weeks apart randomized order of reported insurance type

Did not volunteer their insurance status If given appointment without being asked, confirmed

insurance accepted

Outcome variables: Ability to schedule appointment

Wait-time for appointments

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Clinic

ALL APPOINTMENTS CANCELLED IMMEDIATELY

“All Kids” “BC/BS”

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Specialty Type Health Condition Age Referred By

Dermatology Severe atopic dermatitis 9 mos PCP

ENT Obstructive sleep apnea and chronic bilateral otitis media

5 yrs PCP

Endocrine Type 1 diabetes 7 yrs PCP

Neurology New onset afebrile seizures 8 yrs ED and PCP

Orthopedic Fractured forearm, through growth plate

12 yrs ED and PCP

Psychiatry Acute, severe depression 13 yrs PCP

Allergy-Immunology /Pulmonary Diseases

Persistent and uncontrolled asthma

14 yrs ED and PCP

Dentistry Fractured front tooth with pain 10 yrs ED

Medical Specialty Appointments

Disparities in Access2/3rds of Children with Medicaid/CHIP denied care

Medical Specialty Wait Times

Disparities in Wait-timesChildren with Medicaid/CHIP had to wait 22 days longer

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Low, slow, no payments, admin hassle factors Institutional Pressures[Developmental pediatrician, academic hospital]“Yeah, we are cutting down. In the last budget revision, we were called, you know, ‘You are losing money, so you need to improve your patient mix’…So what we’re doing is just trying to restrict the number of Medicaid patients… we have a number of slots for Medicaid, a limited number of slots actually.”

Specialists=30 & PCPs=14 who treat children

Why and how does this happen?Open-ended semi-structured interviews

Providers identified strategies used to allocate scarce specialty care appointment slots

1. Severity of patient’s health condition

2. Taking responsibility for patients who lack alternatives

3. Geographic proximity of patient’s home address or location of the referring PCP

4. Hospital affiliation of PCP

5. Personal connection or professional courtesy with PCP

6. Informal exchange arrangements with PCP

7. Send them to the Emergency Department

The ED as Access Provider

[Otolaryngologist] “So some patients who can’t get an appointment will go to the ER and get sent that way….and once they are in the system…I am obligated to see them.”

[Pediatrician] “The idea is that if I send them to the emergency room and they need to be referred to a specialist, they get a specialist. So I’m bypassing a number of problems. I’m fully aware that I’m crowding the emergency room.”

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Implications for spending scarce resources15

Target providers already caring for publicly-insured

Incentives to increase the presence of specialty practices in low income communities

Resource allocation to AMC/ACOs contingent on equity across both dimensions of access

Large National Experiment!BIG Problems with US healthcare Attempted Remedy

Insure ~32 million by 2019

Primary Care Medical homes

Population-based health

Health IT

Prevention and wellness

P4P Individual & community outcomes

Incentives for system redesign ACOs

Disincentives for over-utilization

Control costs bundling payments/alternative

payment models

Increase care coordination

DECREASE FRAGMENTATION OF CARE

Millions of Americans uninsured

Lack of care coordination

Not evidence-based, unsafe

Low quality, inefficient

Wasteful, fragmented

Inequitable, disparities

Not patient-centered

Overuse, Underuse

Poor health outcomes

Rising costs

Fragmentation of CareC

are

Frag

men

tatio

n

Time/# health problems/# providers/# sites of care/#transitions/#EHRs, etc.

Change in Specialty Care Delivery?

The current visit-dependent paradigm for the delivery of specialty care in the United States contributes to inefficient and ineffective health care.

PCP Specialist PCP SpecialistMedical Home

Medical Neighborhood

Remove geographic &temporal boundaries

Next Step: Affordability! 19

Affordable Care Act

Conclusions

Pre-ACA, we found significant disparities in access to outpatient specialty care for children, attributableto provider non-acceptance of public insurance.

Post-ACA there remain many challenges but also opportunities for improving care delivery

Need for on-going monitoring Access/Equity Quality Affordability Patient experience Health outcomes

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EXTRA SLIDES

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Background: 42 Million U.S. Children Are Publicly Insured

Medicaid/CHIP Entitlement programs

(poor economy => more eligible)

Federal Law* “Medicaid must provide the same access to services that is available to privately insured children living in the same geographic area”

Yet in 2010, the Office of Inspector General of DHHS found most children in nine states did not receive Medicaid-required preventive screenings (DHHS, OEI-05-08-00520)

23* Omnibus Budget Reconciliation Act of 1989, P.L. 101-239, Sec. 6402

Kaiser Family Foundation, statehealthfacts.org

AMC-affiliation = 45% decrease in discriminatory denials

Wait time 41 days longer if Child has Medicaid

Simulated Patient StudiesStandardized Patient/Mystery Shopping/Audit Methodology

Education/feedback

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Quality Assurance

Measure discrimination

Participant Observation FactitiousPatient

Audit Research to Inform Public PolicySTRENGTHS

Studies real world behavior: what people do, not what they say

• Persuasive, not subject to selection, response, or recall bias

Studies the system not individuals

Protects human subjects (IRB)

Benefits anticipated to outweigh harms (monitor system capacity and inequity)

Experimental design

Can control for confounders

Isolates the impact of the variable you are studying

WEAKNESSES

Deceptive design

Not feasible to get consent, would influence “business as usual”

Only studies entry into the market place (Access not Quality)

Does not identify reasons for the observed behavior

Need comprehensive lists, from which to randomly sample

Must be able to supply same information a real patient would have , (e.g. insurance numbers)

Expert Panel MembersMEDICAL EXPERT PANEL

Fuad Baroody, MD

Kelly Carter, MBA

Janet Currie, PhD

Diana Cutts, MD

Matthew M. Davis, MD MAPP

Paul F. Detjen, MD

Chris Forrest, MD PhD

Karen Goldstein, MD MPH MA

Colleen Grogan, PhD

Rick Hamilton, PhD

Arden Handler, DrPH

Miriam Kalichman, MD

Genevieve M. Kenney, PhD

Margaret Kirkegaard, MD MPH

Steve Krug, MD

Daniel Johnson, MD

Elizabeth Lee, MS MBA

Dana Levinson, MPH

Richard A. Levy, MD, MBA

Katie Merrell

Gail Patrick, MD MPP

Li d Di d Sh i MA MBA

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ORAL HEALTH EXPERT PANEL•Kelly Carter, MBA•Kathy Chan•Robert J. Collins, DMD MPH•Eileen Crespo, MD•Diana Cutts, MD •Burton Edelstein, DDS MPH•Patrick W. Finnerty, MPA•Raul Garcia, DMD•Shelly Gehshan, MPP•Robert E. Isman, DDS MPH•Ray J. Jurado, DDS•Genevieve M. Kenney, PhD•Lew N. Lampiris, DDS MPH•Stacey McMorrow, PhD•Muzaffar Mirza, DDS